The hospital found that the ward was operating on too few staff, which led to observations being missed.

Cara's mum, Deirdre Robinson, hopes the findings of the inquest will stop it happening again.

Deirdre said: “Nothing can bring Cara back to me, but I hope that now failings have been identified, that they can be swiftly addressed so other parents can be spared the torment of losing a child in this way.

“No other parent should get a call to hear their child has died at Rampton. Lessons must be learned and I want that to be Cara’s legacy.”

Deidre had been concerned about how Cara, from Larne, Northern Ireland, came to be sectioned in Rampton, some 350 miles away from home, as well as how she came into possession of a ligature.

She instructed instructed civil liberties lawyers at Irwin Mitchell to investigate how her daughter came to die despite being under regular observations because of her risk of self-harm.

The jury at the inquest found, among other things, that Cara was not observed every fifteen minutes as she should have been, and that information about her state of mind was not passed onto incoming staff.

It was also found that issues surrounding patient observations should have been identified by the hospital after the death of another patient in 2015.

The jury concluded that although it was not possible on the evidence to say that these shortcomings contributed to her death, they may have done so.

Fiona McGhie, a civil liberties lawyer who represented Deirdre, said: “Cara’s death raised some troubling questions regarding the care she received at Rampton Secure Hospital.

“It is a relief for Deirdre that she now has the answers she has waited so long for, even though they paint a vivid picture of Cara’s last hours at the facility, something that no parent should have to face.

"Of particular concern to her is the fact that the ward was understaffed on the day of Cara’s death and the impact that may have had on the care which she received.

“We sincerely hope that lessons are now learned so that others don’t suffer as Cara did, or as her family continue to do.”

Nottinghamshire Healthcare Trust said changes have since been made.

A spokesperson said: "Nottinghamshire Healthcare would like to offer its sincere condolences to the family and friends of Cara Walls.

"The inquest jury has recorded a conclusion of death by misadventure. The trust apologises unreservedly for the failings that took place in the hours before Cara’s death.

"This was not the standard we expect. It was made plain in the inquest that, following a comprehensive independent investigation, significant changes have since been made – especially in arrangements for observing patients.

"The Trust realises that this is all too late for Cara, but we very much hope that the improvements we have made will help prevent such a tragedy in the future.

"Rampton Hospital cares for some of the most mentally unwell women in the Country. Our staff work hard day and night to keep patients safe. Sadly, on this occasion, Cara was let down. For that, we can only apologise once again."